Antimicrobial Selection in the Face of Nasal Methicillin-Resistant Staphylococcus aureus-Polymerase Chain Recombination Testing in Thermal Injury Patients.

Emergence of resistance to vancomycin and the increasing incidence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) warrant careful initiation of antimicrobial agents after nasal swab polymerase chain recombination (PCR) MRSA positive screen. Current MRSA PCR nasal swab (PCR) screening does not distinguish non-hospital-acquired strains. A retrospective, institutional review board-approved study of collected PCR screenings among 826 burn center admissions over a 23-month period assessed culture results, antimicrobial agents chosen, and patient demographics. Seventy-seven of the 826 were known chronic carriers (n = 11); had MRSA on initial PCR (n = 48); or converted to positive PCR screen on later testing (n = 18). The 48 patients with initial positive PCR were decolonized with mupirocin. MRSA carriers were not decolonized. The 18 patients who became PCR positive were also not decolonized with 10 having positive cultures. The 48 initial PCR nasal swab positive patients represented 5.8% of admissions. Demographic data did not differ among chronic carriers, initial PCR positive patients, nor those converting to PCR positive. Length of stay was shorter for initial PCR positive decolonized patients (P << .05) and they had a 35% of decrease in MRSA infection. All 11 chronic carriers became infected with MRSA; however, five had non-hospital-acquired MRSA and two solely non-hospital-acquired MRSA. For the 48 PCR positive patients, 17 had isolated MRSA and one having exclusively non-hospital-acquired MRSA. Of the 39 patients with isolated MRSA, 20 (43%) non-hospital-acquired MRSA. Non-hospital-acquired MRSA was 43%, however PCR fails to distinguish hospital-acquired MRSA from community-acquired MRSA.

Evaluation of Aquacel Ag for Autogenous Skin Donor Sites.

An ongoing objective of burn research is to evaluate wound dressings and develop new treatments to expedite wound healing. This was a single-center, prospective, randomized, controlled study to evaluate the effectiveness of Aquacel Ag as a dressing for autogenous skin donor sites compared with Xeroform. We hypothesized that donor sites treated with Aquacel Ag would heal faster. Patients were considered for enrollment if they required skin grafting with two donor sites >100 cm at least 2 inches apart. Dressings were observed daily starting on post-op day #2 until discharge and then weekly in the outpatient burn clinic. Assessments evaluated pain, infection, and reapplication. Photographs were taken on post-op day #2, upon "90% re-epithelialization," and at post-op day #30-45. Scar assessments and blinded photographic reviews were completed to assess cosmetic healing. Twenty-nine patients completed the study. Re-epithelialization occurred faster with Xeroform (15.2 days vs. 17.6 days). Daily pain scores were higher with Xeroform (6.72 vs. 5.68) and Aquacel Ag needed to be replaced more often (1.72 times vs. 0.10 times). Three patients developed donor site infections with Aquacel Ag. Scar scores between the donor sites were not statistically significant. The blinded photo review concluded that Xeroform had a better cosmetic outcome (24 vs. 10%). Although patients complained of more pain with Xeroform, it demonstrated shorter healing times and better cosmetic outcomes. Aquacel Ag needed to be replaced more often and represented the only three donor site infections.

Pyoderma gangrenosum: a difficult diagnosis best managed in a burn treatment center.

Pyoderma gangrenosum (PG) is a rare immunological disorder with inexplicable white blood cell infiltration into the epidermis with necrosis and excruciating pain. Diagnosis is by exclusion which delays proper treatment. Surgical intervention often exacerbates wounds. Between 2004 and 2010, seven patients with PG were admitted to our burn treatment center (BTC). Multiple treatment modalities were used on these patients. An institutional review board-approved retrospective study investigated seven PG BTC admissions. Demographic information, symptom onset, time to diagnosis, admission or transfer, length of stay (LOS), use of corticosteroids, and prior surgery were collected. The average time to PG diagnosis was 18.7 days and the average wound surface area was 3.9%. The average patient age was 64.6 years (median 66 years) and there were five men and two women patients. The average symptom onset was 70.5 days prior to BTC admission. The BTC wound care lasted 24 days. Six of the seven patients had lower extremity lesions vs one with lesions involving the abdomen. Inflammatory bowel disease was noted in two patients, one with malignant melanoma, and another with psoriasis. Corticosteroids were begun 1.75 days after admission for six of the seven patients. Of the seven PG patients, five had excision and/or skin grafting with vacuum-assisted wound closure used in four. Six patients were discharged, but one patient succumbed early to sepsis. Skin grafting often speeds up chronic wound closure; however for PG this causes progression of lesions. Persistent non-healing wounds with pain disproportionate to size may be PG. Prompt diagnosis and BTC specialized care greatly improve outcomes for PG patients.